Federal Reports

The Office of National Drug Control Policy (ONDCP) leads and coordinates the Nation’s drug policy to improve the health and lives of the American people, including the development and implementation of the National Drug Control Strategy (the Strategy).  ONDCP evaluates the effectiveness of national drug control policy efforts, the Strategy’s goals and objectives, and each National Drug Control Program Agency’s program-level measures.  On February 27, 2024, after determining the U.S. Department of Housing and Urban Development’s (HUD) program-level performance measures were missing numeric data to determine the extent HUD’s programs contributed to the Strategy, ONDCP requested that HUD Office of Inspector General (OIG) review HUD’s fiscal year (FY) 2023 performance measures.  We initiated an audit to obtain the FY 2023 performance measures for HUD’s Continuum of Care Program (CoC) and Recovery Housing Program (RHP), to determine whether they accurately reflect program performance, and identify challenges the programs have experienced in developing and reporting performance measures.

HUD does not provide ONDCP with annual numeric targets for its CoC and RHP performance measures, but rather designates these performance metrics as tracking indicators used to contribute to ONDCP’s overall performance reporting on reducing overdoses in the United States.  HUD is hesitant to set annual numeric targets for CoCs because the primary focus of the program is to provide housing to individuals and families experiencing homelessness and not specific to people with substance use issues.  HUD is also hesitant to set annual numerical targets for RHP grantees because the program is a pilot program and potential issues with setting annual targets for multi-year RHP grants.  In addition, HUD cannot provide ONDCP actual results for CoC grantees by ONDCP’s designated annual November 1st deadline because CoC grantee data is not available to HUD until months after the deadline.  HUD uses a January 2018 ONDCP-approved reporting methodology to report CoC performance measures.  However, this reporting methodology does not allow ONDCP to fully capture the extent of the CoC and RHP programs’ contribution to the Strategy’s overall goal and objective of reducing overdose deaths in the United States.

In addition, HUD does not have formal policies and procedures for ONDCP reporting requirements which may increase the risk of reporting inconsistencies and impacts knowledge retention.

HUD can improve its performance reporting measures by collaborating with ONDCP on reporting methodologies that ensure performance measures can be reported by ONDCP’s November 1st deadline.  HUD should also establish formal reporting policies and procedures and written agreements with ONDCP that reflect the collaborative effort on alternative reporting methodologies.  By taking these actions, HUD will improve HUD and ONDCP’s ability to fully capture the programs’ contributions towards reducing overdose deaths in the United States.

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

The Tennessee Valley Authority (TVA) provides credit cards, known as the TVA One Card, to its employees to make purchases for TVA business, such as materials and supplies, travel, meetings and events, fuel for rental vehicles, management expenses, and services.  TVA transitioned from separate corporate credit cards and purchasing cards to the TVA One Card in 2022 and implemented a new expense management system.  For the 12-month period of May 1, 2023, through April 30, 2024, purchases made on the TVA One Card totaled $86.6 million.

We conducted an audit of TVA One Card purchases due to the recent introduction of the program and amount of annual spending. Our objective was to determine if purchases made using the TVA One Card complied with TVA policies and procedures. Our audit scope included approximately $59.2 million of TVA One Card purchases, which excluded those for travel/transportation, business meetings, and external relationship events, made during the 12-month period of May 1, 2023, through April 30, 2024. 

We reviewed supporting documentation uploaded in the expense management system for a sample of 139 purchases made using the TVA One Card and determined all but one of the purchases appeared to be for TVA business purposes.  However, we determined the review and approval process was not operating effectively and did not ensure purchases made with the TVA One Card complied with TVA policies and procedures.  Specifically, we found instances where (1) management approved purchases that did not fully comply with TVA policies and procedures, and (2) management’s review of purchases prior to expense report approval did not include reviewing the attached receipts.  Additionally, we determined cardholders were not consistently submitting purchases for approval in the expense management system within the required time frame.

An Amtrak carman based in Miami, Florida, resigned from his position on March 17, 2025, following an interview with our agents. Our investigation found that the former employee violated company policies by leaving work early so he could report to a second job. The former employee is not eligible for rehire. Previously, another employee identified in this investigation also resigned from his position.

We assessed whether USGS administered a cooperative agreement with the Colorado School of Mines for a new facility in accordance with requirements. 

We reviewed the results of prior OIG and Government Accountability Office engagements that were relevant to the to the supplemental disaster funding provided by the American Relief Act, 2025. We identified areas with reported past weaknesses and recommendations that may provide Rural Development (RD) insight when disbursing funds allotted by the Act.

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Washington DC Healthcare System. 

This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued four recommendations for improvement in two domains:
 1.    Environment of care
   •    Crosswalk visibility and pedestrian safety
   •    Blanket warmer temperature
   •    Electrical issue
 2.    Patient safety
   •    Identifying adverse events that warrant institutional disclosures

We reviewed the results of prior OIG and Government Accountability Office engagements that were relevant to the to the supplemental disaster funding provided by the American Relief Act, 2025. We identified areas with reported past weaknesses and recommendations that may provide the Agricultural Research Service's (ARS) insight when disbursing funds allotted by the Act.

NPS generally manages its wastewater systems effectively but has opportunities for improvement.

For our evaluation of the Census Bureau’s recruitment, hiring, and retention of field representatives (FRs), our objective was to evaluate the effectiveness of the strategies the bureau uses to support its recruitment, hiring, and retention of employees in mission-critical positions. Specifically, we reviewed staffing requirements and strategies intended to ensure the bureau recruits, hires, and retains enough FRs to collect survey data. We found that the bureau does not have effective strategies to address staffing gaps and high vacancies in FR positions. Specifically, the bureau did not meet its staffing goals for three major surveys or implement a process to track and assess vacancy information from the regions.

The U.S. Department of Housing and Urban Development (HUD) administers billions in presidentially declared disaster recovery grants through its Community Development Block Grant Disaster Recovery program.  We audited five non-State grantees to assess whether they are on track to spend their remaining grant funds on eligible activities that benefit program participants within a reasonable amount of time.  We also wanted to determine what factors, if any, impacted the grantees’ ability to spend their funds in a timely manner.  These grantees, which include cities, counties and parishes, received grant funds for a variety of disasters occurring from 2011 through 2015, and are still in the process of executing their approved action plans.  HUD considered the five grantees to be “slow spenders” at the beginning of our audit. 

The five grantees are on track to complete eligible activities and spend their remaining funds by grant closeout.  As of May 2, 2024, four of the five grantees had obligated all of their grant funds, and the fifth grantee was approved by HUD in February 2024 to obligate its remaining funds.  Although, as of January 1, 2024, HUD had designated four of the five grantees as slow spenders, it appears all five grantees will complete their planned activities and ultimately assist program beneficiaries.  Grantees either had fully completed planned activities or were on track to complete them, this primarily due to HUD-approved extensions to expenditure or grant closeout deadlines, which allowed grantees to complete planned activities beyond the original estimated completion dates.  However, the grantees will have taken from 7 to 14 years from the date on which they signed their respective grant agreements with HUD to complete their action plans and expend all of their grant funds to address their disaster recovery needs, including restoration or replacement of damaged properties and infrastructure.  All grantees cited challenges in completing projects and spending their disaster recovery funds in a timely manner, such as the coronavirus disease 2019 pandemic, staffing, and disaster recovery grant administration requirements.  

We did not make any recommendations in this report.  

OIG determined whether the Office of the Assistant Secretary for Civil Rights processed final agency decisions and final agency orders for Rural Development’s formal EEO civil rights complaints filed in FY 2022 in a timely manner. 

A train attendant based in Chicago, Illinois, was sentenced on March 12, 2025, in United States District Court, Northern District of Indiana, to two years of probation, and was ordered to pay $65,832 in restitution. Our investigation found that the employee
provided fraudulent documents and made false representations to obtain two Paycheck Protection Program (PPP) loans totaling $40,832, to which he was not entitled. Our investigation also found that the employee provided fraudulent information to the Illinois Housing Development Authority and was awarded a $25,000 grant based upon his false representations.
The employee pleaded guilty on May 14, 2024, to mail fraud.

Why We Did This Report

The Federal Insecticide, Fungicide, and Rodenticide Act, as amended by the Food Quality Protection Act, requires the U.S. Environmental Protection Agency Office of Inspector General to perform an annual audit of the financial statements for the Pesticides Reregistration and Expedited Processing Fund.

Summary of Findings

We rendered an unmodified opinion on the EPA’s fiscal years 2023 and 2022 (Restated) Pesticides Reregistration and Expedited Processing Fund financial statements-also known as the Federal Insecticide, Fungicide, and Rodenticide Act Fund, financial statements, meaning that the statements were fairly presented and free of material misstatement. We noted the following material weakness: the EPA materially misstated the Federal Insecticide, Fungicide, and Rodenticide Act Fund income and expenses from other appropriations.

Our Objective(s)To assess FAA's (1) processes for analyzing data and identifying risks associated with runway incursions, and (2) actions for preventing and mitigating runway incursions at primary commercial service airports. The audit focused on FAA's processes for analyzing runway incursion data and its efforts to prevent and mitigate serious runway incursions (Category A and B) at primary commercial airports since the beginning of fiscal year 2022.
Why This AuditIn early 2023, a series of incidents at large commercial airports occurred in which aircraft came significantly close to each other on runways. FAA has taken various actions in response to these incursions, such as holding a safety summit and granting over $200 million to airports for runway incursion mitigation, but challenges persist.
What We FoundFAA lacks an integrated approach for analyzing runway incursion data and identifying risks.

Runway incursion data is mainly used to conduct analyses to prevent and mitigate runway incursions at individual airports.
FAA does not have all causal data available for analysis or always share data freely across the Agency, preventing it from conducting full-scale analyses and developing corresponding mitigations.
FAA concluded that a review of Aviation Safety Information Analysis and Sharing data did not provide additional context to determine if there were indicators of emerging trends regarding runway incursions.

While FAA has taken some actions to mitigate runway incursions, it has yet to implement several key initiatives.

FAA is in the process of deploying and finalizing key mitigations, most notably deploying new airport surface surveillance and other safety technologies.
In response to the 2023 string of runway incursion incidents, FAA acted to further aviation safety awareness, held discussions with stakeholders, and continued with long-standing mitigation practices.
An independent Safety Review Team issued 24 recommendations in November 2023 in the areas of process integrity, staffing, facilities, equipment, and technology. FAA has only implemented five of these recommendations as of October 2024.

RecommendationsWe made five recommendations to improve FAA's ability to share data between its organizations and to provide stakeholders with pertinent information for preventing and mitigating runway incursions.

Our Objective(s)To assess FAA's oversight of airport sponsors' compliance with the Coronavirus Response and Relief Supplemental Appropriations (CRRSA) Act and the American Rescue Plan Act (ARPA) rent relief and economic relief reimbursement eligibility requirements.
Why This AuditThe CRRSA Act and ARPA awarded $10 billion in economic relief to eligible U.S. airports and concessions at those airports to prevent, prepare for, and respond to the COVID-19 pandemic. By the end of December 2023, FAA had expended more than $8.5 billion in concession rent relief and economic relief grants. We previously identified weaknesses in FAA's policies and procedures for monitoring COVID-19 relief funds. Because of those weaknesses, we initiated this audit.
What We FoundFAA's revised policies have resulted in greater adherence to reimbursement requirements.

Our previous review of FAA's oversight of the COVID-19 relief grant funds determined that the Agency's oversight process regarding supporting documentation impacted its ability to monitor program performance. During that review, we identified $271 million in unsupported costs, $85 million in questioned costs, and $3 million in improper payments.
We recommended that FAA assess the risk of improper payments for different types of Coronavirus Aid, Relief, and Economic Security Act (CARES Act) reimbursement requests and revise its policy on supporting documentation requirements to account for risk level. In response, FAA revised its COVID grant programs guidance, effective March 27, 2023.
With these changes, FAA significantly reduced unsupported and questioned costs, as well as improper payments.

FAA inconsistently implemented the CRRSA Act and ARPA rent relief programs.

To receive rent relief funds, FAA required airport sponsors to complete a Concession Plan. We found that FAA approved 76 percent of Concession Plans for the Airport Coronavirus Response Grant Program (ACRGP) and 70 Percent of Concession Plans for the Airport Rescue Grants Program (ARGP).
Our review of 60 plans identified some inconsistencies in the program's implementation and an error in FAA's review, including a nonprofit business receiving rent relief, inconsistent application of airport lounges' eligibility as concessions, and airport sponsors inconsistently populating data fields for Concession Plans. Despite these inconsistencies we did not identify any significant improper rent economic relief payments in our review sample.

RecommendationsFAA has reduced unsupported and questioned costs and improper payments for ACRGP and ARGP, so we are not making new recommendations.

We audited the U.S. Department of Housing and Urban Development’s (HUD) Office of Multifamily Housing Programs’ monitoring of civil rights compliance.  Robust monitoring for civil rights compliance is critical to HUD’s goals to support underserved communities.  Our audit objective was to assess the extent to which HUD monitored civil rights compliance in its program activities.

HUD and performance-based contract administrators (PBCA) perform minimal monitoring of civil rights compliance when conducting management and occupancy reviews (MOR) for multifamily properties due to (1) a lack of training and emphasis regarding civil rights monitoring and (2) contract issues with the PBCAs.  From April 1, 2021, through December 31, 2023, HUD and the PBCAs monitored civil rights compliance for only 12 multifamily properties from a statistical sample of 132 properties.  By performing minimal monitoring of civil rights compliance, HUD is missing opportunities to identify discriminatory practices or civil rights violations, thereby missing opportunities to report these concerns to the Office of Fair Housing and Equal Opportunity for resolution.

We recommend that HUD’s Deputy Assistant Secretary for Multifamily Housing (1) implement training at the regional level to provide instruction on and stress the importance of monitoring civil rights compliance as part of the MORs conducted, (2) direct HUD staff to perform all required monitoring of civil rights compliance as part of the MORs conducted, (3) instruct the PBCAs to include the completion of the addendum B checklist as part of the MORs performed by the PBCAs, and (4) provide technical training to the multifamily property owners and management agents on monitoring for civil rights compliance as part of the MORs.

We reviewed the results of prior OIG and Government Accountability Office engagements that were relevant to the supplemental disaster and crop insurance funding provided by the American Relief Act, 2025. We identified areas with reported past weaknesses and recommendations that may provide Farm Production and Conservation (FPAC) agencies insight when disbursing funds allotted by the Act.

We reviewed the results of prior OIG and Government Accountability Office engagements that were relevant to the to the supplemental disaster funding provided by the American Relief Act, 2025. We identified areas with reported past weaknesses and recommendations that may provide the Forest Service (FS) insight when disbursing funds allotted by the Act.

We audited the U.S. Department of Housing and Urban Development’s (HUD) Office of Community Planning and Development’s (CPD) monitoring of grantees’ compliance with civil rights requirements. Our audit focused on the Community Development Block Grant (CDBG) and the HOME Investment Partnerships Program (HOME). Our audit objective was to assess the extent to which CPD monitored civil rights compliance in its program activities.

CPD could improve its civil rights compliance monitoring reviews. Specifically, CPD performed civil rights monitoring reviews for 2 percent of the CDBG and HOME grantees it monitored in fiscal year 2023. CPD suspended its limited civil rights monitoring in fiscal years 2021 and 2022 pending the Affirmatively Furthering Fair Housing (AFFH) rules. In fiscal year 2023, it resumed its limited civil rights monitoring. However, guidance issued by management did not instruct staff to conduct civil rights monitoring, which led to confusion among field staff. In addition, CPD could improve its monitoring by requiring its field staff to fully complete the CPD Handbook 6509.2, chapter 22, civil rights monitoring checklists while conducting remote monitoring. Without clear guidance and in depth monitoring reviews, CPD could miss opportunities to identify errors in grantees’ policies, procedures, and practices related to nondiscriminatory responsibilities in CPD programs, thus overlooking the potential to communicate fair housing concerns to HUD’s Office of Fair Housing and Equal Opportunity (FHEO) for resolution.

We recommend that HUD’s General Deputy Assistant Secretary for Community Planning and Development coordinate with FHEO to implement training for civil rights monitoring reviews. Additionally, CPD should (1) ensure that training on civil rights monitoring reviews is regularly provided to CPD staff (such as quarterly, semiannually, etc.); (2) implement updated guidance or protocols for monitoring civil rights compliance and require CPD staff to incorporate civil rights monitoring into the risk analysis process; and (3) develop guidance clarifying the use of the exhibit for on-site, hybrid, and remote monitoring to ensure a full review  of grantees’ compliance with civil rights requirements, and incorporate this guidance into training developed as a result of the first recommendation. HUD took steps during the audit to implement the second recommendation.

This report presents the results of our audit of Fiscal Year 2024 Board of Governors’ Expenditures.

The Office of Inspector General (OIG) initiated this review based upon an assessment of program risks. Our objective was to review the U.S. AbilityOne Commission’s (Commission) enterprise risk management (ERM) program to assess its maturity level, which will provide the Commission with an overall understanding as to where its current ERM program stands.

To answer our review objective, we 1) reviewed laws, regulations, policies, and procedures applicable to the ERM implementation, 2) conducted interviews with key personnel, 3) surveyed Commission leadership and staff to gain their perspectives of the Commission's ERM program for a more comprehensive view of the ERM program maturity, and 4) analyzed data, reports, and other supporting documentation related to ERM.  We conducted this review in accordance with the Quality Standards for Inspection and Evaluation issued by the Council of Inspectors General on Integrity and Efficiency.

There are five levels in the model we used to assess the Commission’s ERM program.  The OIG assessment determined that the Commission’s ERM program maturity is between level 2, emerging, and level 3, integrated.  By conducting its own internal maturity assessment, it can periodically identify gaps in its ERM program and develop plans to mature the program, as necessary.

The OIG has no specific recommendations associated with this report.

The objective of our inspection was to review the U.S. Department of Education’s (Department) administration of its reasonable accommodation program. This included determining whether reasonable accommodation requests were processed timely and in accordance with applicable policies and procedures. We found that improvements are needed in the Department’s processing of reasonable accommodation requests. Specifically, we found that the Department did not always process employee reasonable accommodation requests in accordance with relevant policies and procedures or maintain adequate documentation to allow for a determination of whether it complied with these policies and procedures, including those related to processing timeframes. In addition, we found that the Department did not adequately process applicant reasonable accommodation requests to ensure that accommodations were only provided to applicants with a qualifying disability. We also found that the Department does not have adequate processes to track and report on reasonable accommodation requests. The processes used by the Department do not ensure that all requests are captured, that data specific to the requests is adequately tracked, and that data is properly reported. We also noted issues with the quality of the data included in spreadsheets used by the Department to track and report on reasonable accommodation requests.

In an effort to increase transparency and accountability in the use of Federal funding in program activities, Federal law and guidance requires the U.S. Department of Housing and Urban Development (HUD) and its prime recipients to ensure that complete and accurate subaward data is posted on USASpending.gov.  We audited HUD to determine whether the prime award recipients of HUD funding met all of the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements for their subawards on USASpending.gov, including the amount of the subaward and a description of the products or services provided.  

We found that HUD’s prime award recipients of the Offices of Community Planning and Development (CPD) and Office of Lead Hazard Control and Healthy Homes (OLHCHH) programs did not always report their subawards of $30,000 or greater as required by FFATA.    Specifically, 25 prime awards in CPD programs and 10 prime awards in OLHCHH programs from 2 separate statistical samples of 70 prime awards made at least 1 subaward that they did not report to USASpending.gov.  Additionally, we found that 31 of 68 sampled subawards under the CPD programs were noncompliant with subaward reporting requirements, primarily because the subaward description was not adequate to provide the stakeholders with an understanding of the purpose of the awarded funds.   HUD’s prime award recipients lacked knowledge of the FFATA subaward reporting requirements due to insufficient guidance and oversight by HUD program offices and lack of an enterprise-level policy.  This noncompliance impairs the transparency and accountability of Federal spending, limiting stakeholders’ ability to fully evaluate the use of Federal funds within their communities.

An Amtrak lead service attendant based in Los Angeles, California, resigned from her position on March 7, 2025, in lieu of an administrative hearing. Our investigation found that the former employee violated company policies by engaging in outside employment while on a medical leave of absence and continuing to receive Railroad Retirement Board (RRB) sickness and supplemental sickness benefits during that time, and by making false representations in support of her RRB and unemployment insurance claims. The former employee is not eligible for rehire.

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

The American Relief Act of 2025 provided the U.S. Department of Agriculture (USDA) with approximately $39.8 billion to carry out projects and activities related to agricultural disaster assistance. It also provided USDA Office of Inspector General with $7.5 million for oversight of such projects and activities carried out with the funds made available to USDA under the Act. This document describes our plan to oversee these funds.

The VA Office of Inspector General (OIG) reviewed Veterans Health Administration (VHA) assertions required by the Office of National Drug Control Policy (ONDCP) in its fiscal year 2024 detailed accounting report and budget formulation compliance report. The OIG’s review was conducted in accordance with generally accepted government auditing standards, which incorporate the attestation standards established by the American Institute of Certified Public Accountants. Those standards require that the OIG plan and perform the review to obtain limited assurance about whether any material modifications should be made to management’s assertions for them to be fairly stated. The OIG believes this review provides a reasonable basis for its conclusion. In the detailed accounting report, VHA reported three material weaknesses, three significant deficiencies, and certain matters concerning noncompliance with laws and regulations, as identified in the OIG report Audit of VA’s Financial Statements for Fiscal Years 2024 and 2023. A material weakness is a deficiency, or combination of deficiencies, such that there is a reasonable possibility that a material misstatement of the entity’s financial statements will not be prevented or detected and corrected on a timely basis. A significant deficiency is a control deficiency, or a combination of control deficiencies, that is less severe than a material weakness, yet important enough to merit attention by those charged with governance. Based on the OIG’s review, the OIG is not aware of any material modifications that should be made to VHA management’s assertions for them to be fairly stated.

Departments are required by law to develop and maintain governance structures, controls, and processes to safeguard resources and assets. A robust fraud risk framework helps to ensure that programs fulfill their intended purpose and that funds are spent effectively. HUD relies on public housing authorities (PHAs) to detect and prevent fraud, waste, and abuse in its housing programs.  Therefore, we audited the New York City Housing Authority’s (NYCHA) fraud risk management maturity with the objective of assessing its fraud risk management practices for preventing, detecting, and responding to fraud when administering HUD‐funded programs. We chose NYCHA because it is HUD’s largest PHA, administering billions of dollars in HUD funding and because its programs receive over 25 percent of HUD’s rental assistance funding nationwide.

We found that NYCHA has established several antifraud controls, but its processes to mitigate fraud risks are largely reactive. NYCHA is actively taking steps to formalize a more proactive fraud risk management approach and is progressing toward a more mature antifraud program.  We assessed NYCHA’s antifraud efforts against established best practices to determine the maturity of its fraud risk management practices, and found it to be at an “initial” maturity level. We found NYCHA does not have a comprehensive strategy or framework for identifying and responding to fraud risks. Specifically, it did not (1) assess fraud risks across NYCHA or develop a process to regularly conduct assessments to identify and rank fraud risks, (2) develop a response plan for fraud risks based on a fraud risk assessment, and (3) implement a process to monitor and evaluate the effectiveness of fraud risk management activities.

Due to the size and complexity of NYCHA, as well as its high fraud risk exposure, it should aim for a higher fraud risk maturity level. Without a comprehensive fraud risk management framework or antifraud strategy, HUD funding will continue to be at an increased risk of fraud, and NYCHA will not be positioned to understand how it can best improve its programs to detect fraud or potential fraud.  Further, since HUD has not issued formal guidance to PHAs regarding its expectation of PHAs in assisting HUD with its responsibility to implement fraud risk management activities over HUD programs, it is likely that many PHAs have not implemented formal fraud risk management programs. As a result, HUD is missing a critical control using leading practices that could detect and prevent fraud and minimize fraud risk at the PHA level in the Office of Public and Indian Housing programs that spend approximately $38.5 billion annually on voucher and public housing programs, representing over 50 percent of HUD’s budget.

An Amtrak electrician based in Chicago, Illinois, was terminated from employment on March 7, 2025, following an administrative hearing. Our investigation found that the former employee was arrested and charged with first degree murder and was on a medical leave of absence while incarcerated.

San Jose Immigration Lawyer Extradited From The Kyrgyz Republic To Face Charges Of Large-Scale Visa Fraud

Federal Jury Convicts Joshua Aaron Holmes For Conspiracy To Commit Mail And Wire Fraud

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Dublin Healthcare System in Georgia. 

This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued eight recommendations for improvement in three domains:
 1.    Environment of care
   •    Navigational signage
   •    Toxic exposure program oversight and screening navigator roles and responsibilities
   •    Clean and safe patient care areas
   •    Biohazard storage area contents, signage, and hand-washing supplies and equipment
   •    Environment of care trends, performance improvement plans, and outcome measures
 2.    Patient safety
   •    Ordering providers communicate and document test results
   •    Facility-level policies and standard operating procedures comply with VHA requirements
 3.    Veteran-centered safety net
   •    Homeless program staff have appropriate vehicles

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine how surgical instruments that were not suitable for service (nonconforming instruments) were used during a patient procedure at the Carl Vinson VA Medical Center (facility) in Dublin, Georgia. The OIG identified Sterile Processing Service (SPS)-related deficiencies as well as a continuation of previously identified deficiencies.

The OIG determined that SPS and operating room staff failed to remove nonconforming surgical instruments from a rectal tray that was used during a patient procedure. Moreover, the OIG found additional surgical instruments in nonconforming condition and that, contrary to policy, the reprocessing and use of nonconforming instruments was a permitted practice at the facility.

Additionally, facility leaders failed to establish a preventative maintenance program for the sharpening, repair, or replacement of surgical instruments prior to May 30, 2024.

The OIG also identified a continuation of previously identified deficiencies that included: the failure of facility leaders to fully implement an electronic surgical instrument tracking system known as CensiTrac, address concerns of the CensiTrac coordinator’s performance, and resolve concerns related to the intended use of an SPS conference and training room. Frequent changes in staff assigned to leadership positions, along with leaders’ failures identified above, likely contributed to the continued SPS deficiencies.

The OIG made two recommendations to the Facility Director related to ensuring staff’s compliance with identification and disposition of nonconforming surgical instruments and training operating room staff to recognize nonconforming surgical instruments. The OIG made three recommendations to the Veterans Integrated Service Network Director related to reviewing patients potentially affected by nonconforming instruments, evaluating whether administrative action is warranted for individuals regarding SPS deficiencies at the facility, and performing oversight of the facility’s implementation of facility-level action plans and sustainability of identified outcomes. 

The Veterans Health Administration (VHA) Grant and Per Diem (GPD) program funds community-based transitional housing for veterans experiencing homelessness. An OIG administrative investigation examined VHA’s oversight of the Veterans Village of San Diego (VVSD), a GPD program grantee providing drug treatment and other services. 

The OIG found that staff at the VA San Diego Healthcare System (the VA facility) responsible for local oversight of VVSD were aware that in 2021 and through most of 2022, issues with drug sales by non-VA residents, drug use, and insufficient staffing increased risks to veterans co-located there. However, VA facility staff did not take timely or effective action to ensure VVSD remediated these issues. Local facility staff lacked important information related to residents at VVSD who were funded by non-VA entities. Also, a regional official responsible for GPD oversight did not provide adequate support. Finally, the OIG found that the GPD National Program Office could have provided clearer guidance on key issues, such as when certain grantee enforcement measures should be used and how to redress recurrent grant noncompliance issues.

The OIG followed up the initial investigation with a limited review of VHA oversight of VVSD through September 2024, prompted in part by reports that improvements may not have taken hold. The investigation revealed that issues related to veteran care and safety, and a lack of information about co-located non-VA residents, recurred or persisted at VVSD. 

VHA concurred with the OIG’s finding and five recommendations to improve governing policies, training, or other guidance, and appropriate follow-up for GPD-funded residents at VVSD who lost access to drug treatment services there. VHA provided acceptable action plans and completion timelines. The OIG will monitor VA’s progress until sufficient documentation has been received to close the recommendations as implemented.

Why We Did This Report

The U.S. Environmental Protection Agency Office of Inspector General performed this audit pursuant to the Hazardous Waste Electronic Manifest Establishment Act. The Act requires the EPA to prepare and the OIG to audit the accompanying financial statements of the EPA’s Hazardous Waste Electronic Manifest System Fund.

Summary of Findings

We rendered an unmodified opinion on the EPA’s fiscal years 2023 and 2022 Hazardous Waste Electronic Manifest System Fund, known as the e-Manifest Fund, financial statements, meaning that the statements were fairly presented and free of material misstatement. We did not identify any matters that we consider to be material weaknesses or significant deficiencies in the fund.

We have reviewed the system of quality control for the audit organization of the National Railroad Passenger Corporation (Amtrak) Office of Inspector General (OIG) in effect for the year ended September 30, 2024. A system of quality control encompasses Amtrak OIG’s organizational structure, and the policies adopted, and procedures established to provide it with reasonable assurance of conforming in all material respects with Government Auditing Standards1 and applicable legal and regulatory requirements. The elements of quality control are described in Government Auditing Standards. 

In our opinion, the system of quality control for the audit organization of Amtrak OIG in effect for the year ended September 30, 2024, has been suitably designed and complied with to provide Amtrak OIG with reasonable assurance of performing and reporting in conformity with applicable professional standards and applicable legal and regulatory requirements in all material respects. 

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Central Western Massachusetts Healthcare System in Leeds. 

This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued one recommendation for improvement in one domain:
1.    Environment of care
   •    Leaders assess storage locations outside of standard supply rooms and implement a process to ensure staff remove expired supplies

A former executive of a Chicago-area non-profit organization has pleaded guilty to a federal fraud charge for her role in misappropriating $1.8 million intended to support the charity’s work with underprivileged youth.

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient care delivered at the Edward P. Boland VA Medical Center, part of the VA Central Western Massachusetts Healthcare System (facility) in Leeds.

The facility met some VHA requirements for inpatient mental health units, including providing the required amount of interdisciplinary programming for veterans and the completion of twice-yearly environment of care inspections. The inpatient unit included some aspects of a recovery-oriented physical environment, such as soft night lighting in the nurses’ station and veterans’ rooms.

Electronic health record reviews indicated most veterans were involved with the interdisciplinary treatment team in treatment planning, and veterans had documented safety plans. However, some records did not include evidence of timely suicide risk screenings, and discharge instructions were difficult to understand, lacking important details for appointment follow-up and medication management.

The facility did not have an established local mental health executive council or an interdisciplinary safety inspection team during the review period. The facility’s admission policy did not include processes for the admission of veterans on an involuntary hold. The facility leaders lacked formal processes to monitor and track compliance with involuntary commitment state laws.

The OIG identified environment of care deficiencies such as the unit’s sally port entrance doors were not synchronized; the inpatient unit had unweighted, unsecured chairs in a group room; and facility staff did not have a policy that addressed the use of a restraint chair. Additionally, many staff did not have evidence of completed environment of care or suicide prevention trainings. 

The OIG issued 16 recommendations to facility leaders. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health unit and beyond.

We contracted with Williams, Adley & Company-DC, LLP (Williams Adley) to examine the effectiveness of the CFTC’s ERM process as well as its maturity. Williams Adley conducted the audit in accordance with Generally Accepted Government Auditing Standards (GAGAS) and is responsible for the attached audit report and the conclusions expressed therein.1 The OIG monitored the auditor’s progress throughout the performance audit and reviewed the respective audit report and related documentation.

The National Credit Union Administration (NCUA) Office of Inspector General (OIG) conducted this self-initiated audit to assess the Central Liquidity Facility (CLF). The objectives of our audit were to determine: (1) whether the NCUA operates the CLF in accordance with relevant laws, regulations, policies, and procedures; and (2) the utilization of the CLF by credit unions covered by the temporary authority granted by the CARES Act.

Results of our audit determined the NCUA operated the CLF in accordance with applicable laws and substantially complied with regulations and its own policies and procedures. We determined the annual stock adjustment done by the CLF was not entirely done in accordance with regulations as the CLF did not receive payments for adjustments to member capital stock subscriptions no later than March 31. However, we determined the financial impact of these payments not being received by March 31 was de minimis. We also determined the CLF was being utilized as evidenced by its growth in members. While we are making no recommendations in our report to management, we are suggesting management determine whether they want to pursue any action to extend the due date beyond March 31st for the annual stock adjustment payments to the CLF.

To learn how communities across the nation responded to the pandemic, we initiated a multi-part review of six communities—two cities, two rural counties, and two Tribal reservations. This report is the fourth community-specific report and focuses on our work in White Earth Nation Reservation in Minnesota, where we previously identified that recipients, including city government, small businesses, and individuals, received almost $278 million from 56 pandemic relief programs and subprograms. This report provides a closer look at ten pandemic programs and subprograms provided to White Earth Nation Reservation by seven federal departments.

We audited loanDepot.com to evaluate its quality control (QC) program for originating and underwriting Single Family Federal Housing Administration (FHA)-insured loans.  We selected loanDepot for review based on its loan volume and delinquency rate and because its rate of self-reporting loans to HUD when it identified fraud, material misrepresentations, and other material findings that it could not mitigate was below average for more than a 5-year period.

 We found that loanDepot’s QC program for originating and underwriting FHA-insured loans was not sufficient.  Specifically, loanDepot (1) did not select the proper number of loans for review and maintain complete and accurate data to document its loan selection process; (2) missed material deficiencies; and (3) did not adequately assess, mitigate, and report loan review findings, which included self-reporting loans to HUD when required.  These issues occurred because loanDepot had insufficient controls over its QC program.  As a result, HUD did not have assurance that loanDepot’s QC program fully achieved its intended purposes, which include, among other things, protecting the FHA insurance fund and lender from unacceptable risk, guarding against fraud, and ensuring timely and appropriate corrective action. 

 We recommended that HUD require loanDepot to (1) update its QC plan and related procedures to align with HUD requirements; (2) provide training to its staff and management on HUD requirements for lender QC programs; (3) review the loans that it had not selected and take appropriate actions when applicable; and (4) evaluate its QC files for the loans in which it identified material findings to confirm whether it self-reported to HUD all findings of fraud or material misrepresentation, along with any other material findings that it did not acceptably mitigate.

The Office of Inspector General (OIG) is issuing this report to show those recommendations from U.S. Small Business Administration (SBA) Office of Inspector General (OIG) reports that remained open as of December 31, 2024. As of that date, there were 166 open OIG recommendations. SBA provided updates for certain recommendations prior to the date of this report which may still be under review by OIG. The status of each recommendation is subject to change as we independently review SBA’s ongoing implementation.

The Transportation Security Administration (TSA) shared intelligence and engaged with industry stakeholders to enhance passenger rail security and preparedness. Specifically, TSA shared threat information and intelligence products and assessed passenger rail systems to identify security vulnerabilities and mitigate risks. In addition, TSA provided workshops and training to passenger rail system owners and operators to help them better secure their operations.